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2. JANUARY 2024 WELLNESS CHALLENGE
6. FIRST NAME*
7. MIDDLE INITIAL
8. LAST NAME*
10. EMAIL ADDRESS:*
12. BEST CONTACT NUMBER*
14. WATER TRACKER

    Upload your January 2024 Wellness Challenge Tracker to receive credit and eligibility for a prize!

18. DID YOUR HAIR, SKIN, NAILS, AND WELL-BEING IMPROVE THROUGH THE MONTH?*

    1. YES
    2. NO
20. COMMENTS
22. Do you agree that your monthly wellness tracker is honest?*

    1. I DO
24. 2. Do you understand that any prizes awarded for your participation in the Monthly Wellness Challenge will count as income, and therefore taxed at the end of the year?*

    1. I DO

28. YOUR ELECTRONIC SIGNATURE BELOW INDICATES THAT YOU HAVE SUBMITTED YOUR MONTHLY WELLNESS PARTICIPATION ON YOUR OWN BEHALF.

30. EMPLOYEE SIGNATURE*
31. DATE SIGNED*
    DATE SIGNED
Leave This Blank:


33. 1. Receive an email copy of this form.
34. Email address

    This field is not part of the form submission.

35. Submit

* indicates a required field